Why is the government interested in VAP?

Your question: Why is the government interested in reducing nosocomial pneumonia and VAP?

My answer:  While the powers that be will tell you that the main emphasis of efforts to reduce nosocomial infections such as ventilator associated pneumonia (VAP) are to improve patient outcomes, this is not the complete truth.  Any time you have insurance companies and the government involved in the creation of guidelines to improve outcomes, the ultimate goal, or the bottom line, is saving money.

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Subglottic suctioning

Nearly every study done on the subject shows that the leading cause of ventilator associated pneumonia to be caused by secretions pooling above the endotracheal tube cuff, resulting in gradual, micro-aspiration.

According to studies done as far back as 2002 and reported on by the Centers for Disease Control and Prevention (CDC) suggest that subglottic suctioning may help reduce the risk for micro-aspiration.

A CDC report notes:

The endotracheal tube prevents glottic closure. As a result, the patient is unable to cough and remove secretions in a natural way. However, accumulation or pooling of oropharyngeal secretions above the endotracheal tube cuff occurs and then these fluids can be aspirated. See figure. 

Removal of these secretions by suction can reduce the risk of aspiration and may be the most cost effective and safe intervention. Four studies have shown subglottic suction to be safe and effective,14,38-40while only one study showed no difference in colonization. Figure 2 shows one method of performing subglottic suction with a separate suction catheter placed into the sub-glottic area.

Various ETTs are now available that allow for subglottic suctioning. Studies suggest that ETT that allow for subglottic suctioning help reduce the risk for VAP.
Whether an institution has them depends on budget, and on how the powers that be perceive the results of the various studies.

References:

1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002, http://en.haiwatch.com/data/upload/tools/VAP_CEU_Booklet_Z0406.pdf, Kimberly Clark Co., accessed 4/21/14
2. "Intubation And VAP: A Complex Condition Requires Bundled Solution," rtmagazine.com, http://www.rtmagazine.com/2014/04/intubation-vap-complex-condition-bundled-solutions/, accessed 4/23/14

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What is the treatment for VAP?

Question:  What is the treatment of ventilator associated pneumonia (VAP)?

Answer:  Treatment is usually a broad spectrum antibiotic until the specific bug and effective antibiotic is isolated. Other than that, treatment generally includes supportive, and may include oxygen therapy, beta adrenergic therapy, bed rest, etc.  An effort should be made to maintain adequate oxygen saturation.  If a patient cannot maintain an SpO2 of 92% or greater, or 88% or greater if the patient has a chronic lung disease, then BiPAP therapy, or intubation and mechanical ventilation, must be considered as options

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Ventilator bundle to prevent Ventilator Associated Pneumonia

By the late 1990s it was known that about 15% of patients intubated and placed on a ventilator acquired what was then termed ventilator associated pneumonia (VAP), and that about 30% of those with VAP would ultimately die.  A major effort was then begun to try to reduce these numbers.

Solid data was now available that allowed the Centers for Disease Control and Prevention (CDC) to compile guidelines for combating VAT.  Considering the limited options for treating pneumonia, the main effort was aimed at prevention.

The initial guidelines included many of the following.  These are often referred to as the essential parts of a "Ventilator Bundle."

1. Mandatory Education:  Everyone involved in the care of the patient should be aware of VAP and how to prevent and treat it.
2. Mandatory Infection Control:  Everyone taking care of the patient, including visitors, should be aware of the hospitals infection policy.  The best method of spreading infections is by frequent and vigorous hand washing. This may also include wearing masks and gowns when necessary. Sterile technique should be followed when inserting lines or drawing blood.
3. Routine Oral Hygiene:  Since bacteria from the upper airway may pool over the cuff, it is essential to keep the upper airway clean.  Many guidelines recommend oral suctioning and cleaning at least every two hours. 
4. Regular Change-out policy:  Closed suction systems and suction canisters and tubing should be changed every 24 hours.  Ventilator circuits should remain closed at all times, and changed at least once a week.  
5. Maintain Closed circuit:  The ventilator circuit should remain closed at all times.  Special adapters can be added to the circuit to introduce breathing treatment and metered dose inhalers.  Closed suction systems such as a ballard can be introduced between the ETT and the "Y" to prevent the need to break the circuit in order to suction.  Heated circuits prevent condensation inside the circuit and reduce the need to open the circuit for water removal. Changing ventilator circuits weekly instead of daily may also help reduce the introduction of bacteria to the patient. 
6. Limit normal saline introduction:  The introduction of normal saline into the ETT to assist with the removal of thick secretions should not be routinely performed by nurses, and should only be done by respiratory therapists on an as needed basis. 
7. Stress ulcer prophylaxis:  Since gastric contents may work their way to the upper airway and into the lungs, efforts must be made to prevent this.  Since all patients on a ventilator are at increased risk for stress fracture, they should all be treated for this. 
8. Ventilator extubation protocols:  Creation of weaning protocols are shown to speed up time from intubation to extubation. This forces clinicians to start thinking about weaning the moment a patient is intubated. 
9. Maintain cuff pressure:  Studies show that a cuff pressure of 30 or greater prevents the micro-aspiration of secretions that pool over the cuff.  To read further about this read the post "What tracheal cuff pressure measurement is ideal?" Cuff pressure should be measured and recorded each shift. While the ETT should be rotated each shift, unnecessary maneuvering of the tube should be avoided.  Also, the cuff pressure should never be less than 20 in adults as this significantly increases the risk of aspiration.  Vigorous suctioning should be performed before rotating the cuff and prior to deflating the cuff.  (1, page 8)
10. Elevate head 30-45 degrees:  This should prevent the aspiration of stomach contents.  This should be required in all ventialtor care policies. 
11. Prevent early extubation:  ETT should be adequately secured, and the patient adequately sedated or watched in order to prevent inadvertent or purposeful early patient extubation.  Ventilator protocols should help guide clinicians as to the best extubation time.  
12. Consider tracheotomy:  If a patient should need to be on a ventilator more than a week, the patient should be trached. Trachs also allow for normal physiologic swallow mechanisms which prevent secretions and stomach contents from being inhaled.  They also make it easier to wean patients, make it so less sedation is required, reduced airway resistance, and enhances secretion removal. It allows application of speaking valves to allow patient to speak, even while on ventilator.  Studies show they also improve overall patient morale.  
13. Avoid heated moisture exchangers (HME):  Do not use HMEs unless absolutely necessary, such as when you need to transfer the patient. Studies have linked them with an increased risk for VAP. 
14. Limit sedatives:  This topic continues to be controversial and debated.  Some experts recommend limiting the use of sedatives in the early mornings to make sure the patient awake enough for weaning trials.  Ideally, sedatives should be stopped at least four hours prior to doing weaning parameters or weaning attempts.  However, some experts suggest that some sedatives allow patient to be alert enough to follow commands.  
15. Daily Chest X-Ray:  Since it is very difficult to know when a patient is developing pneumonia, it is important to have a chest x-ray every morning in order to monitor patient's lungs for signs of pneumonia.  
16. Prophylactic antibiotic therapy:  Some experts recommend automatically starting patients on a broad spectrum antibiotic to prevent the development of infection.  This is also recommended as the top line treatment for VAP.  
17. Obtain sputum ASAP after intubation:  Obtaining a sputum sample immediately after intubation will help determine if the patient already has pneumonia, or confirm that the patient did not have pneumonia.  This will help determine if a pneumonia is pre-existing or caused by the ventilator. 
18. Cleaning equipment: Equipment must be efficiently cleaned between patients in order to prevent contamination from one patient to the next. 
19. Lower tidal volumes:  These may reduce the inflammatory response seen by higher tidal volumes.  
20. Serial Lab tests:  Daily laboratory testing can help determine if white blood cell counts are increasing, or other markers, which will show that a patient has an infection. 

This post will be updated as new wisdom is obtained.  The following graphic from the CDC pretty much sums it up.

References:

1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002, http://en.haiwatch.com/data/upload/tools/VAP_CEU_Booklet_Z0406.pdf, Kimberly Clark Co., accessed 4/21/14
2. "Protocols and Definitions Device-associated Models: Ventilator Associated Pneumonia," Centers for Disease Control, http://www.cdc.gov/nhsn/PDFs/slides/VAP-DA_gcm.pdf, accessed 4/21/14
3. "Intubation And VAP: A Complex Condition Requires Bundled Solution," rtmagazine.com, http://www.rtmagazine.com/2014/04/intubation-vap-complex-condition-bundled-solutions/, accessed 4/23/14

Signs and symptoms of ventilator associated pneumonia (VAP)

According to the Centers for Disease Control and Prevention (CDD), the following are generally considered the signs and symptoms of ventilator associated pneumonia (VAP.

• Chest X-ray showing new or progressive diffuse infiltrate which is not attributable to any other cause
• Onset of purulent sputum
• Fever greater than 38.5°C (101°F)
• Leukocytosis
• Positive sputum or blood cultures

Leading causes of nosocomial infectjions

It was around 1972 that studies started to come back showing that patients admitted to hospitals were at an increased risk of infection. It was about this time when the term nosocomial infections started to be used in reference to infections caused by the hospital.

By 2002, studies returned the following results as reported by the Centers for Disease Control and Prevention (CDC)/:

1.  Urinary infections are the most common at 31%, and were linked to indwelling urinary catheters.
2.  Pneumonia is the second most common at 27%, and was linked to intubation and ventilation
3.  Blood stream infections were the third most common at 19%, and were linked to indwelling intravenous catheters

It was these statistics that inspired hospital orientated programs to investigate their causes and methods of their dissolution.

Ventilator associated pneumonia (VAP) statistics

Ventilator associated pneumonia (VAP)  was first recognized around 1972, and by 2002 the Centers for Disease Control and Prevention (CDC) released guidelines designed to prevent VAP.  Since these guidelines were passed the statistics actually look pretty good.

While VAP statistics vary from study to study, the following are some of the results:

1. Pneumonia is the second most common nosocomial infection in the United States at 27% (urinary tract infections is number one at 31%, and blood stream infections is #3 at 19%), according to the CDC
2. Pneumonia is a leading cause of death due to hospital-acquired infections.
3. In 2002, US hospitals reported an estimated 250,000 cases of healthcare-associated pneumonias—36,000 related to deaths, according to the CDC
4. 5-20% of patients wo require mechanical ventilation for greater than 48 hours will develop VAP, and th associated mortality is 15-50%, according to Lorente et al and Porzecanski et al
5. ICU stays in patients with VAP is increased by a mean of 6.1 days, and the excess cost can be as high as $40,000 per patient, according to Restrepo et al and Warren et al. 
6. The VAP death rate is 30%, or between 27% and 43%
7. In 2007, The incidence of VAP in 2007 was 22.8% 
8. In 20007, VAP account for 86% of all cases of nosocomial pneumonia.
9. In 2007, intubated patients had a 3-10 fold greater risk of catching pneumonia
10. The mortality rate attributable to VAP is 27% 
11. The mortality rate is as high as 43% when the causative agent was antibiotic resistant
12. Length of stay in the intensive care unit is increased by 5 to 7 days
13. Hospital length of stay was increased 2- to 3-fold
14. In 2014, the cost is estimated to be an additional $40,000 per hospital admission per patient, and an estimated $1.2 billion per year.
15. By 2012, the number of VAP incidents dropped to 3,957
16. With each day of mechanical ventilation and intubation, the crude VAP rate increases by 1% to 3% and the death risk increases from two-fold to 10-fold
17. The American Thoracic Society reported that ventilator-associated pneumonia occurs in 9% to 27% of all intubated patients.
18. A study published in the American Journal of Respiratory and Critical Care Medicine indicated that an estimated 5.9% of ICU deaths through day 60 could be attributed to VAP.
19. Healthcare costs can increase more than $57,000 per incident of VAP.
20. VAP prevention can reduce both the cost and morbidity associated with mechanical ventilation.

Early statistics, which did not look good, were used as incentives to create guidelines for institutions to institute policies and procedures to reduce these rates. Later statistics show these efforts have worked.

References:

1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002, http://en.haiwatch.com/data/upload/tools/VAP_CEU_Booklet_Z0406.pdf, Kimberly Clark Co., accessed 4/21/14
2. "Protocols and Definitions Device-associated Models: Ventilator Associated Pneumonia," Centers for Disease Control, http://www.cdc.gov/nhsn/PDFs/slides/VAP-DA_gcm.pdf, accessed 4/21/14
3. "Intubation And VAP: A Complex Condition Requires Bundled Solution," rtmagazine.com, http://www.rtmagazine.com/2014/04/intubation-vap-complex-condition-bundled-solutions/, accessed 4/23/14
4. Bowton, David L, R. Duncan Hite, Shayne Martin, and Robert Sheretz, "The Impace of Hospital-Wide Use of a Tapered-Cuff Endotracheal Tube on the Incidence of Ventilator-Associated-Pneumonia," Respiratory Care, October, 2013, volume 58, number 10, pages 1582-1587

What causes VAP?

Secretions pool above the ETT cuff,
resulting in gradual aspiration.

The first studies linking pneumonia and ventilators started coming out in 1972. While it was first thought pathogens came from the equipment, subsequent studies confirmed that the pathogens came from the patient.  

By 2002, it was known that the pathogens came from either secretions that pooled in the upper airway, or those accumulated in the upper GI tract, and then were aspirated, thereby increasing the risk for developing Ventilator Associated Pneumonia (VAP). 

It was at this time that VAP was also broken down into early onset and late onset (1, page 3):

1. Early Onset: The infection occurs within 48-96 hours of admission, and is generally associated antibiotic sensitive agents, such as:
• Staphylococcus aureus (gram positive)
• Haemophilus influenzae (gram negative)
• Streptococcus pneumoniae (gram positive)
2. Late Onset: The infection occurs 96 hours after intubation, and is generally associated with bacteria that are tough to kill, such as:
• Methicillin Resistant Staphylococcus aureus (MRSA)
• Acinetobacter or Enterobacter 
• Pseudomonas aeruginosa (1, page 3)(2)

In most cases, VAP is associated with more than one causative agent.

The various bacterial agents known to colonize in the lungs of ventilator patients have been known to come from various sources within the body, including: (2)

• Oropharynx (mouth and throat)
• Sinus Cavities (nasal drainage)
• Nares
• Dental Plaque
• Gastrointestinal tract
• Patient to patient (poor hand washing by clinicians)
• Ventilator circuit (2)

It's not necessarily the ventilator itself that raises the risk for pneumonia, but the cuffed endotracheal tube (ETT).  Secretions containing bacteria pool above the cuff, and may be forced into the lower airway during the various activities performed by caregivers, such as:  (2) (1, page 4)(3, page 1583)

• Ventilator induced breaths 
• Instillation of saline into the ETT
• Suctioning
• Coughing
• Repositioning the ETT   (1, page 4)

Complicating this problem is that the ETT prevents normal physiological functions meant to keep the lungs sterile. The resulting factor is an increased risk for developing pneumonia while intubated. (1, page 4)

Other reasons the ETT may cause VAP: (1, page 4)

• It prevents a natural cough
• It prevents humidification of upper airway (causing dry mouth)
• Inhibits upper airway reflexes, such as cough and sneeze
• Inhibits cilliary transport of germs to the upper airway
• Allows germs to bypass the upper airway, allowing them direct access to the lungs
• Act as a reservoir for pathogens by providing a place for biofilm to form
• Having a cuff provides a place for secretions to pool (as noted above) (1, page 4)

There are also certain factors associated with an increased risk: (1, page 4)

• Over age 65
• Underlying chronic illness (COPD, asthma, GERD)
• Immunosuppression (AIDS)
• Depressed consciousness (Sedated, paralyzed)
• Thoracic or abdominal surgery
• Previous antibiotic therapy
• Previous pneumonia or remote infection
• Nasogastric tube placement
• Bolus enteral feeding 
• Gastric over-distension
• Stress ulcer treatment
• Supine patient position (lying flat on back)
• Nasal intubation route
• Instillation of normal saline
• Understaffing 
• Non-conformance to handwashing protocol
• Indiscriminate use of antibiotics
• Lack of training in VAP prevention (1, page 4)

So, you can see here how patients who require intubation and mechanical ventilation are at an increased risk for developing VAP.  Once this information made its way to the mainstream guidelines, protocols, and order sets (Ventilator Bundles) were created in order to attempt to reduce the incidence thereof.

References:

1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002, http://en.haiwatch.com/data/upload/tools/VAP_CEU_Booklet_Z0406.pdf, Kimberly Clark Co., accessed 4/21/14
2. Augustyn, Beth, "Ventilator Associated Pneumonia: Risk Factors and Prevention,"  Critical Care Nurse, August, 2007, volume 27, number 4, pages 32-29
3. Bowton, David L, R. Duncan Hite, Shayne Martin, and Robert Sheretz, "The Impace of Hospital-Wide Use of a Tapered-Cuff Endotracheal Tube on the Incidence of Ventilator-Associated-Pneumonia," Respiratory Care, October, 2013, volume 58, number 10, pages 1582-1587

The birth of ventilator associated pneumonia (VAP)?

The battle against ventilator acquired pneumonia (VAP) began around 1972.  At this time evidence began to show "the airway of mechanically ventilated patients quickly becomes colonized with gram-negative organisms." (1, page 2)

No one knew about VAP during the 1950s, a time when the wisdom and technology became available to artificially breathe for sick people.  It was first used in operating rooms to breathe for anesthetized patients, although it quickly made it's way to emergency rooms.  It was, of sorts, a revolutionary breakthrough in medicine.  

The initial theory was that the pathogens came from the equipment used, although, as the evidence started to mount, this theory was proven false.  It soon became obvious that the causative agent came from the patient by two primary processes:

1. Bacterial colonization of the upper airway and upper digestive
2. The subsequent aspiration into the lower airway

The medical condition described here soon became known as ventilator acquired pneumonia, also known as VAP.  In order to further study and evaluate it, a definition was needed: 

Pneumonia in patients who have been on mechanical ventilation for greater than 48 hours.

The Centers for Disease Control and Prevention continues to use this definition.  It is assumed that the patient did not have pneumonia at the time of intubation.

Since added to this definition is the following:

Pneumonia that develops within 48 hours of discharge from a location.

So even if the patient has be extubated and is presently among the general population of the hospital, the patient can still be diagnosed with VAP if the patient was on a ventilator continuously at any time during that previous 48 hours. (2, page 10)

Since 1972, much has been learned about VAP and how to treat and, mainly, prevent its occurrence.

References:

1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002, http://en.haiwatch.com/data/upload/tools/VAP_CEU_Booklet_Z0406.pdf, Kimberly Clark Co., accessed 4/21/14
2. "Protocols and Definitions Device-associated Models: Ventilator Associated Pneumonia," Centers for Disease Control, http://www.cdc.gov/nhsn/PDFs/slides/VAP-DA_gcm.pdf, accessed 4/21/14